Healthcare Provider Details

I. General information

NPI: 1003960253
Provider Name (Legal Business Name): AGNES B FUENTES DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2445 ARMY NAVY DR SUITE 100
ARLINGTON VA
22206-2905
US

IV. Provider business mailing address

2445 ARMY NAVY DR SUITE 100
ARLINGTON VA
22206-2905
US

V. Phone/Fax

Practice location:
  • Phone: 703-521-7802
  • Fax: 703-521-7803
Mailing address:
  • Phone: 703-521-7802
  • Fax: 703-521-7803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberVA7231
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: